Prevalence Of Antipsychotic Polypharmacy Research Articles

Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients

ABSTRACT This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi2 or Fisher’s exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi2, p = 0.010), olanzapine (Fisher’s test, p = 0.003), and aripiprazole (Fisher’s test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi2, p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.

Antipsychotic treatment in elderly patients on polypharmacy with schizophrenia.

Elderly patients with schizophrenia (SCH) are treated with antipsychotics and are often on different comedications, including polypharmacy (five or more medications). Evidence-based guidelines and randomized controlled trials do not include patients on polypharmacy, something that represents a 'gap' between evidence-based recommendations and clinical prescribing patterns. In this context, narrative reviews are needed to help clinicians in daily practice. Antipsychotic treatment efficacies in meta-analyses are similar in the elderly with SCH compared with the general population (medium effect size). Long-term cohort studies show that antipsychotic treatment reduces overall mortality, hospitalizations, and cardiovascular death. These studies are limited because polypharmacy was not studied. The prevalence of antipsychotic use as potentially inappropriate medications was very high in nursing homes (25%). The prevalence of antipsychotic polypharmacy was 40%. Different strategies to manage these problems are available, including collaboration with clinical pharmacists, leading to reduced polypharmacy and better adherence to treatment guidelines. Elderly patients with SCH on polypharmacy are less frequently studied, although they represent many patients with SCH. Different potentially inappropriate medication lists and collaboration with clinical pharmacists represent effective strategies for medication optimization. More studies are needed on this topic (e.g., prospective nonrandomized studies).

Antipsychotic Polypharmacy.

Physicians who treat patients with schizophrenia frequently encounter complex clinical situations not fully addressed by published treatment guidelines. Some of these situations lead to antipsychotic polypharmacy, often prescribed when clinical and social obstacles prevent access to clozapine and patients have had suboptimal responses to nonclozapine monotherapy. We offer our perspective on the place of antipsychotic polypharmacy in the current treatment guidelines for patients with schizophrenia. We summarize data on the prevalence of antipsychotic polypharmacy and describe common clinical situations in which this practice is encountered, along with the pharmacological underpinnings of this practice. We briefly review evidence on common risks of antipsychotic polypharmacy and describe the limited evidence for the possible benefits of such practice. Moreover, we take a look at alternative antipsychotic augmentation strategies that address all domains of psychosis.

Psychotropic polypharmacy in Australia, 2006 to 2015: a descriptive cohort study.

To describe psychotropic polypharmacy in Australia between 2006 and 2015. We used pharmaceutical claims from a national 10% sample of people with complete dispensing histories to estimate the annual prevalence of the combined use (overlap of >60days exposure) of ≥2 psychotropics overall and within the same class or subclass (class and subclass polypharmacy). We also estimated the proportion of polypharmacy episodes involving one, two, three and four or more unique prescribers. The prevalence of class polypharmacy between 2006 and 2015 in people dispensed specific psychotropic classes was 5.9-7.3% for antipsychotics, 2.1-3.7% for antidepressants and 4.3-2.9% for benzodiazepines. The prevalence of antipsychotic polypharmacy was higher than expected given the prevalence of antipsychotic exposure and combinations of sedating agents were notably common. Overall, 26.7% of polypharmacy episodes involved multiple prescribers but having multiple prescribers occurred more frequently for class and subclass polypharmacy and people with four or more concomitant psychotropics. Psychotropic polypharmacy is common, despite limited evidence of risks and benefits. Increases in polypharmacy with multiple prescribers may be due to poor communication with patients and between health care professionals.

Prevalence of and factors associated with antipsychotic polypharmacy in patients with serious mental illness: Findings from a cross-sectional study in an upper-middle-income country.

Objective:The aim of our study was to examine the prevalence of and factors associated with antipsychotic polypharmacy (APP) among patients with serious mental illness in the current South African health care context.Methods:We collected data on patient, illness, and treatment characteristics of patients discharged on one or more antipsychotic agents from January to June 2014. We analyzed the associations of APP with demographic and clinical variables using hierarchical multivariable logistic regression, and examined prescription patterns.Results:The prevalence of APP in our study population of 577 patients was 28.4%. Demographic and clinical characteristics significantly associated with APP included age > 29, male sex, diagnosis of schizophrenia, comorbid intellectual disability, comorbid substance use, greater number of hospital admissions, and high-dose prescribing. First-generation antipsychotics and long-acting injectable preparations were prominent in APP combinations. Co-prescription of anticholinergic agents and sodium valproate demonstrated a significant association with APP.Conclusion:APP appears common in our population, despite lack of evidence for the practice and possible risk of harm. Our findings suggest a complex interplay among patient, illness, and treatment factors relevant to APP in our setting that could be targeted for intervention.

Antipsychotic Medication Prescribing Practices Among Adult Patients Discharged From State Psychiatric Inpatient Hospitals.

The goal of this study was to explore antipsychotic medication prescribing practices in a sample of 86,034 patients discharged from state psychiatric inpatient hospitals and to find the prevalence of patients discharged with no antipsychotic medications, on antipsychotic monotherapy, and on antipsychotic polypharmacy. For patients discharged on antipsychotic polypharmacy, the study explored the adjusted rates of antipsychotic polypharmacy, the reasons patients were discharged on antipsychotic polypharmacy, the proportion of antipsychotic polypharmacy by mental health disorder, and the characteristics associated with being discharged on antipsychotic polypharmacy. This cross-sectional study analyzed all discharges for adult patients (18 to 64 y of age) from state psychiatric inpatient hospitals between January 1 and December 31, 2011. The relationship among variables was explored using χ, t test, and analysis of variance. Logistic regression was used to determine predictors of antipsychotic polypharmacy. The prevalence of antipsychotic polypharmacy was 12%. Of the discharged patients receiving at least 1 antipsychotic medication (adjusted rate), 18% were on antipsychotic polypharmacy. The strongest predictors of antipsychotic polypharmacy being prescribed were having a diagnosis of schizophrenia and a length of stay of 90 days or more. Patients were prescribed antipsychotic polypharmacy primarily to reduce their symptoms. Antipsychotic polypharmacy continues at a high enough rate to affect nearly 10,000 patients with a diagnosis of schizophrenia each year in state psychiatric inpatient hospitals. Further analysis of the clinical presentation of these patients may highlight particular aspects of the illness and its previous treatment that are contributing to practices outside the best-practice guideline. An increased understanding of trend data, patient characteristics, and national benchmarks provides an opportunity for decision-making that is sensitive to the patient's needs and cognizant of the hospital's accomplishments in adopting best practices.

Clozapine treatment and discontinuation in Iceland: A national longitudinal study using electronic patient records

Background: Clozapine is the only drug approved for treatment-resistant schizophrenia. There is evidence that clozapine is underutilized. Aims: To evaluate the initiation and discontinuation of clozapine at Landspitali University Hospital in Iceland and the prevalence of antipsychotic polypharmacy in clozapine-treated patients. Methods: The study is a part of an ongoing longitudinal study of schizophrenia in Iceland. We identified 201 patients on clozapine or who have been on clozapine by using a keyword search in the electronic health records and by reviewing their medical records. Results: Mean age at first treatment with clozapine was 37.8 years. Mean follow-up period on clozapine was 11 years. After 20 years of treatment 71.2% of patients were still on clozapine. After one year of treatment 84.4% of patients were still receiving clozapine treatment. We estimate that 11.4% of patients with schizophrenia in Iceland are taking clozapine and that 16% have been treated with clozapine at some point. Polypharmacy is common, since nearly 2/3, 65.6%, of patients taking clozapine use at least one other antipsychotic and 16.9% are also receiving depot injections. Conclusions: We need to increase the awareness of psychiatrists in Iceland with regard to treatment with clozapine, since only about half of the estimated population of patients with treatment-resistant schizophrenia in Iceland have ever been treated with clozapine. Nearly two thirds of patients who are prescribed clozapine in Iceland remain on it long-term.

Antipsychotic polypharmacy at the clinic of psychiatry, clinical centre of Serbia

IntroductionAntipsychotic polypharmacy is not supported by current guidelines. However, it is often present in practice. A common reason for this is to gain a greater, faster therapeutic response and reduce the doses of individual drugs, thus reducing the adverse effects.Aims and ObjectivesThe aim of this study is to analyze the prevalence of antipsychotic polypharmacy at the Clinic of Psychiatry, Clinical Centre of Serbia and to compare it with the data from 10 years ago when similar research was conducted.Material and methodsThis is a cross-sectional study conducted in 2015. The data were obtained from the patients’ charts and compared with the results of a more extensive study conducted at the same hospital during 2002–2005 period. Statistics was performed using standard statistical methods.ResultsOf the total number of patients (n = 44), 81.8% (n = 36) were on antipsychotic monotherapy, while in the previous study, which included 198 patients, monotherapy was noted in just 32.3% hospitalizations (n = 64) (Chi = 34.5; P < 0.001). Among patients treated with polypharmacy, the majority was prescribed the combination of a first- and second-generation antipsychotic (n = 7, 87.5%), while just one patient was treated with two first-generation antispychotics (n = 1, 12.5%). In the 2002–2005 period, the combination of two first-generation antipsychotics was dominant (58.9%, n = 79).ConclusionThis study indicates that in Serbian psychiatry there is a strong tendency towards reduction of antipsychotic polypharmacy. However, this is a single-centre study with a relatively small number of participants and more extensive research on the national level is warranted to confirm this trend.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Prevalence of Antipsychotic Polypharmacy and Associated Factors among Outpatients with Schizophrenia Attending Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

Background. Despite recommendations by guidelines to avoid combinations of antipsychotics unless after multiple trials of antipsychotic monotherapy, it is quite a common practice to use combinations. This practice leads to unnecessary expenses and exposes the patient to severe drug adverse effects. Methods. An institution based cross-sectional study was conducted from April to May 2014. Systematic random sampling technique was used to select 423 study subjects. Logistic regression analysis was conducted to identify associated factors of antipsychotic polypharmacy among schizophrenia outpatients. Result. The overall prevalence of antipsychotic polypharmacy was found to be 28.2%. Extra pyramidal side effects (AOR = 2.80; 95% CI: 1.38, 5.71), repeated psychiatric hospitalization (AOR = 2.83; 95% CI: 1.45, 5.50), history of substance use (AOR = 2.82; 95% CI: 1.36, 5.88), longer duration of treatment (AOR = 2.10; 95% CI: 1.14, 3.87), and drug nonadherence (AOR = 1.84; 95% CI: 1.14, 2.98) were found to be significantly associated with antipsychotic polypharmacy. Conclusion. Prevalence of antipsychotic polypharmacy was found to be high among the current study participants. Individuals who had extra pyramidal side effects, admission, substance use, duration of treatment, and drug nonadherence were associated with antipsychotic polypharmacy.

Prevalence of Antipsychotic Polypharmacy: Prescribing Practices at the Psychiatry Department at HMC (Hamad Medical Corporation, Doha, Qatar)

Combining antipsychotics in the treatment of schizophrenia and other psychotic disorders is relatively common. Rates in the literature have varied with an average ranging from 10% to 40% [1]. A recently published systematic review that summarized 173 studies reporting on rates and correlates of antipsychotic polypharmacy from the 1970s to today in over 1.5 million patients found that the overall mean antipsychotic polypharmacy rate was 26% [2]. Concerns about antipsychotic polypharmacy include the possibility of higher than necessary numbers of medications, greater than necessary total dosages, increased acute and long-term adverse effects, drug-drug interactions, increased non-adherence, difficulties in determining the effect of each treatment, substantially higher cost, a risk for increased mortality, and the general lack of evidence for the effectiveness and safety of antipsychotic polypharmacy [3-8]. It is our observation that despite the lack of clinical evidence, the anti-psychotic prescribing practices are very prevalent in our department. So far there was no quantitative or qualitative study that looked into this important issue. But there is little literature evidences found regarding the benefits of adding another antipsychotic. We are set to review the prescribing practices at the department of Psychiatry, HMC, in regard to the Antipsychotic polypharmacy, and see how it compares to the international general psychiatric practice then compare it to the existing guidelines. The results are discussed, recommendations are drafted and we plan on follow up in a separate yet later study the progress we would made in bringing about any change in the prescribing behavior after a remedial one year of educational intervention.

Prevalence and nature of antipsychotic polypharmacy among inpatients with schizophrenia spectrum disorders at an Australian mental health service.

Though antipsychotic polypharmacy (APP) is widely utilised in many clinical settings for the treatment of people with schizophrenia, the extent of this practice varies considerably between different regions, countries and clinical settings. Studies from Australasia exploring the prevalence and factors associated with APP are sparse and have yielded inconsistent results. We conducted a systematic retrospective audit of the medical records of all admissions in 2010 in the adult wards of a metropolitan public mental health service in Western Australia, having a diagnosis of schizophrenia or schizoaffective disorder. We analysed the rates of APP use, and its association with selected demographic and clinical variables. The prevalence of APP among our sample of 229 patients was high, at 43.2%. APP was associated with a longer hospital stay (p=0.033) and voluntary admission (p=0.027); but APP was not significantly related to: age, gender, diagnosis and treatment by different psychiatrists. Substantial difference exists between everyday clinical practice and recommendations of practice guidelines of schizophrenia, regarding the use of APP. Prospective studies from different settings exploring the relevant clinical, patient, prescriber and system-related issues are warranted, to comprehend the rationale behind high utilisation of APP in clinical practice.

Antipsychotic polypharmacy among a nationwide sample of community-dwelling persons with Alzheimer's disease.

Antipsychotic polypharmacy (APP) is not recommended in treatment of behavioral and psychological symptoms of dementia (BPSD). There is lack of studies concerning prevalence of APP among persons with dementia. The objective of our study was to describe prevalence and risk factors associated with antipsychotic polypharmacy among antipsychotic users with Alzheimer's disease (AD). Data from nationwide MEDALZ-2005 cohort including all community-dwelling persons diagnosed with AD in Finland was utilized. Register-based data included prescriptions, comorbidities, and hospital discharge diagnoses. Users of antipsychotics during 2006-2009 were included (n = 9,803). The risk of starting antipsychotic polypharmacy was evaluated with Cox proportional hazards model. Prevalence of antipsychotic polypharmacy was 8% (n = 750) among antipsychotic users (n = 9,803). Quetiapine and risperidone was the most common combination of two antipsychotics followed by combination of quetiapine and haloperidol. Antipsychotic polypharmacy was associated with younger age (HR 1.35 [Confidence Interval, CI, 1.16-1.56]), male gender (HR 1.18 [CI 1.02-1.38]), and history of psychiatric disorder (HR 1.50 [CI 1.26-1.78]) in the adjusted model. In conclusion, we found higher prevalence of APP than previously reported among older populations. This is concerning since effectiveness of APP has not been demonstrated and APP is not recommended in the treatment of BPSD. Clinicians should pay more attention to avoid APP and use of antipsychotics to other indications than BPSD among persons with AD.

Antipsychotic polypharmacy in schizophrenia patients in China and its association with treatment satisfaction and quality of life: findings of the third national survey on use of psychotropic medications in China.

This study examined the use, demographic and clinical correlates of antipsychotic polypharmacy (APP) and its associations with treatment satisfaction and quality of life (QOL) in schizophrenia patients in China. A total of 4239 patients in 45 nationwide Chinese psychiatric hospitals/centers were interviewed in 2012 in the third cross-sectional study, with the first two having been conducted in 2002 and 2006. Patients' socio-demographic and clinical characteristics, including psychopathology, side effects, satisfaction with treatment and QOL, were recorded using a standardized protocol and data collection procedure. The proportion of APP prescriptions in 2012 was 34.2%, which was significantly higher than the frequency of APP in 2002 (26.1%) and 2006 (26.4%) (p<0.001). Of patients on APP, 91.1% received two antipsychotics, 8.6% received three and 0.3% received four or more antipsychotics. Multiple logistic regression analyses revealed that compared to those on antipsychotic monotherapy, patients on APP and their families had lower satisfaction with treatment, had higher QOL in the mental domain, younger age of onset, more side effects, higher doses of antipsychotics and were more likely to receive first-generation antipsychotics and less likely to receive benzodiazepines (total R (2)=0.31, p<0.001). APP was found in about one in three schizophrenia patients. The prevalence of APP seems to have been increasing since 2002. Considering the increased frequency of drug-induced side effects and the patients' and their relatives' dissatisfaction with antipsychotic treatment, further examination of the rationale and appropriateness of APP and its alternatives is warranted.

The prevalence of antipsychotic polypharmacy in schizophrenic patients discharged from psychiatric units in Poland

BackgroundThe term antipsychotic polypharmacy (APP) refers to the concurrent use of two or more antipsychotic drugs in schizophrenia. The aim of this study was to investigate the range of APP in schizophrenic patients discharged from psychiatric units in Poland, and to determine its demographical and clinical correlates. MethodsData on the pharmacological treatment of 207 patients with a diagnosis of schizophrenia, discharged from six psychiatric hospitals from September–December 2011 were recorded by experienced psychiatrists. Clinical and demographical information was obtained on each patient. The severity of symptoms at admission, and their improvement during hospitalization were assessed using the Clinical Global Impression Scale. ResultsAt discharge, 52.7% of the patients were prescribed one, 42.5% two and 4.8% three antipsychotic drugs (AP). When two AP were applied, it was usually a combination of two second generation antipsychotics (SGA) (46%), or of both first generation antipsychotics (FGA) and SGA (48%). The SGA's olanzapine and risperidone were those most commonly prescribed. Patients treated with two or more AP had a higher number of previous hospitalizations than patients receiving antipsychotic monotherapy. Mood stabilizers were prescribed for nearly one third of the patients, while antidepressants and benzodiazepines were prescribed for fewer than 10%. ConclusionsThe prevalence of polypharmacy in Poland is similar to that reported in other countries. This may suggest that, in a substantial proportion of schizophrenic patients clinical response to the antipsychotic monotherapy is unsatisfactory. Further studies focusing on the efficacy and safety of strategies in the treatment of patients with schizophrenia not responding to antipsychotic monotherapy are necessary.

Payer types associated with antipsychotic polypharmacy in an ambulatory care setting

Abstract Objectives Antipsychotic polypharmacy is increasingly prescribed despite little documented evidence of a therapeutic benefit. There is also a limited understanding of the role that health insurance plays on the prevalence of antipsychotic polypharmacy. This study was undertaken to investigate the relationship between antipsychotic polypharmacy and individuals' intended source of payment in a US national sample of ambulatory care patients. Methods The study combined 2002, 2003 and 2004 data from the National Ambulatory Medical Care Survey (NAMCS) among adults seeking outpatient-based physician medical care services in the USA. We investigated characteristic differences among patients who were prescribed multiple antipsychotics versus individuals receiving only a single antipsychotic medication. Multivariable logistic regression examined the association between antipsychotic polypharmacy and patients' primary payment type classified as private insurance, Medicaid, Medicare or other (primarily out-of-pocket) payment type. Key findings Use of more than one antipsychotic agent was recorded in 68 of 830 (8.2%) outpatient physician visits in the 3-year period 2002–2004. Among the payer types studied, Medicaid payment status was correlated with increased risk of antipsychotic polypharmacy (odds ratio 2.7, 95% confidence interval 1.1–6.7). Conclusions Insurance status was associated with antipsychotic polypharmacy among non-institutionalized US residents prescribed antipsychotic medications. Patients reporting Medicaid as their primary payer were nearly three times as likely to be prescribed multiple antipsychotic drugs, potentially increasing their risk of adverse side effects as well as greater taxpayer burden. Future research should determine whether these trends continued after 2004 and to determine the costs of treating patients in the public sector with multiple antipsychotic drugs, a common scenario despite financial pressures and uncertain medical benefit.

P-1100 - Pattern of antipsychotic use and its determinants in iran

Antipsychotic monotherapy is recognized as the treatment of choice for patients with psychosis but concurrent use is increasingly common among both inpatients and outpatients. Previous studies of the prescription patterns of psychotropic medications in psychotic patients have highlighted a high rate of antipsychotic polypharmacy, but data in Iran are sparse. This study seeks to analyze prescribing patterns of antipsychotic use and to estimate associated risks in this patient group. The aim of this study was to investigate the prevalence and its determinants of Antipsychotic Use in patients with psychiatric disorders in the greatest psychiatric hospital (Razi) in Iran. This study was on patients with psychiatric disorder that have discharged from the hospital during four months. We have assessed all patients with psychiatric interview and evaluation of their psychiatric documentations. Results of this study indicated that the most prevalent of psychiatric diagnosis was schizophrenia (33.42%) and then Bipolar I Disorder, Schizoaffective Disorder, Mental Retardation and Amphetamine-Induced Psychotic Disorder. 90.7% of all of patients had taken antipsychotic medications and antipsychotic polypharmacy was in 27.2% of these patients. The most prevalent component of antipsychotic polypharmacy was consisting of Chlorpromazine, Halopreidol and Chlorpromazine, Risperidone and then Chlorpromazine, Olanzapine respectively. There were significant relations between pattern of antipsychotic use and gender, occupation status, type of psychiatric ward, duration of hospitalization and cost of treatment but no relationship with age, educational status and duration of illness. This study suggests that prevalence of antipsychotic polypharmacy is high in in-patient psychiatric patients.

Impact of feedback from pharmacists in reducing antipsychotic polypharmacy in schizophrenia

The objective was to examine effects of active interventions on physician's prescribing of antipsychotic polypharmacy. Prescriptions for patients with schizophrenia at the Centre for Addiction and Mental Health, Canada were collected in 2006 (n = 648) and 2008 (n = 778). During the intervening period, a pharmacist monitored prescriptions with antipsychotic polypharmacy and contacted corresponding prescribers to provide education on risks of polypharmacy. Moreover, educational sessions on polypharmacy were presented to inpatient and outpatient teams. A three-fold decrease in the prevalence of antipsychotic polypharmacy was observed between 2006 (18.3%) and 2008 (6.6%). Thus, active monitoring of prescriptions with educational interventions could reduce antipsychotic polypharmacy.

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.

How expensive is antipsychotic polypharmacy? Experience from five US state Medicaid programs

ABSTRACTObjective: To characterize healthcare costs associated with antipsychotic polypharmacy and to investigate predictors of high-cost patients.Methods: A retrospective cohort study using Medicaid claims data from California, Nebraska, Oregon, Utah, and Wyoming evaluated 55 383 fee-for-service patients with antipsychotic prescriptions between 1998 and 2002. Polypharmacy was defined as initiating multiple antipsychotic drugs or concomitant antipsychotic therapy (≥ 60 days). Healthcare costs (drug and non-drug) were summed for 365 days following index antipsychotic claim. Adjusted mean costs were compared to antipsychotic monotherapy. Logistic regression was performed to identify predictors of high-cost patients (top quintile) with regard to patient age, gender, race/ethnicity, mental disorders, hospitalization, index antipsychotic, concomitant psychotropic drugs, and polypharmacy.Results: The average annual prevalence of antipsychotic polypharmacy was 6%. 70–80% of total healthcare expenditures for polypharmacy patients were drug-related. Polypharmacy was associated with significantly higher drug expenditures ($1716–2079) in the year following drug initiation than monotherapy even after adjusting for case mix and index antipsychotic ( p < 0.05). Differences in non-drug expenditures versus monotherapy were smaller and varied by state ranging from a $77 increase in California ( p < 0.001) to a $211 savings in Utah ( p = 0.02). In California, polypharmacy alone (OR = 2.69; 95% CI: 2.30–3.16) or in combination with concomitant psychotropics (OR = 6.26; 95% CI: 5.51–7.11) was associated with greater likelihood of being a high-cost patient than monotherapy.Conclusions: Cost savings from limiting antipsychotic polypharmacy could be significant. Caution must be taken in ensuring reductions in polypharmacy do not lead to unintended consequences or shift care to more costly alternatives. Study limitations, including the known shortcomings of claims data and differences across state Medicaid programs, should be considered when interpreting the results of this or any multi-state study.

Antipsychotic polypharmacy.

The administration of more than one drug for a single medical condition is considered to be polypharmacy. There are many possible reasons for polypharmacy: (1) psychosis is a chronic disease that cannot be cured; (2) expectations to improve patients' quality of life beyond what drugs can actually do is high; (3) the lack of side effects and interactions can cause physicians to be more daring in terms of potential complications; (4) information from the Internet may cause patients and their families to demand medications; (5) the diluted mental health system allows legal guardians and other mental health professionals to force physicians to provide multiple drugs; (6) many new drugs are available; and (7) physicians are forced to shorten hospitalization days. The 1997 American Psychiatric Association Practice Research Network found that 17% of 146 patients with schizophrenia were treated concurrently with more than one antipsychotic medication. Polypharmacy may increase the risk of adverse effects, drug interactions, noncompliance, and medication errors. It is not wise to use polypharmacy only to prevent side effects and drug and interactions. Our attempts to reduce polypharmacy may fail, as academicians also propagate polypharmacy, and all of the algorithms indicate polypharmacy as an option, putting physicians in a legal and ethical bind. Techniques such as experimental ward, peer review, computer information feedback, and comparing different techniques may temporarily reduce polypharmacy but long-term outcome is not affected. Scientific data on the efficacy of polypharmacy is needed in order to sort out good and bad polypharmacy.