Psychotropic Prescribing Practices Research Articles

Quality Improvements in Dementia Care in an Acute Hospital Setting

Abstract Background Dementia care in acute hospital settings requires targeted quality improvement initiatives based on national standards. This poster highlights key interventions to enhance care, aligning with local hospital group key performance indicators (KPIs), in one large teaching hospital. Methods Delirium screening (4AT) was implemented in the Emergency Department and geriatric ward, with education to increase staff awareness of delirium screening, prevention, and management. Audits assessed compliance with the 4AT tool. An audit evaluated the geriatric ward environment, including dementia-friendly painting, decorating, and signage, at baseline. Psychotropic prescribing practices were audited in 20 inpatient charts. A Life story Information tool (Sunflower Tool) was implemented to display personalized patient information at the end of the bed. Semi-annual audits assessed usage and effectiveness in the geriatric ward. Results The initial audit showed 85% compliance with the 4AT tool, dropping to 40% in a repeat audit after 6 months. Initially, 17 of 20 charts had complete 4AT scores; in the re-audit, 11 of 20 had scores recorded, with only 8 fully completed. The first environmental audit revealed poor compliance with dementia-friendly standards, especially in signage, clutter, and bedroom colour contrasts. Best compliance was seen with colour contrast in bathroom toilets and handrails. A quality improvement plan was developed to address gaps. The adoption and impact of the Sunflower tool improved patient-staff interactions and personalized care. All ward staff were trained in using the Sunflower tool. Conclusion A robust quality improvement plan, with measurable, achievable, relevant, and time-defined actions, aligned with national standards and local KPIs, is crucial to achieve and sustain positive audit results. Continuous education, resource allocation, and regular audits are required to ensure high-quality care for patients with dementia. Future efforts will focus on addressing identified challenges, refining interventions based on audit feedback, and maintaining care improvements.

A STOMP-focused evaluation of prescribing practices in one assessment and treatment unit for people with intellectual disabilities

PurposeThis study aims to understand whether psychotropic prescribing practices for people with intellectual disabilities are in keeping with best practice guidelines.Design/methodology/approachThis service evaluation project was a retrospective analysis of routinely collected data from the care records of all 36 people with intellectual disability discharged from an intellectual disability assessment and treatment unit during the first five years of the Stop Over medicating People with Intellectual Disabilities and/or autistic people (STOMP) initiative. Data were gathered at four time points (pre-admission, discharge, 6- and 12-month follow-up) before being analysed to understand whether psychotropic prescribing differed among people with different clinical characteristics/traits/diagnoses. Changes over time were also explored to ascertain whether and how prescribing altered from admission to discharge, and over the subsequent year of community living.FindingsMost people with intellectual disabilities left the assessment and treatment unit on fewer regular psychotropic medications and at lower doses than at admission. These optimised regimes were still apparent 12 months post-discharge, suggesting effective discharge planning and community care packages. Inpatients with severe intellectual disabilities generally received more anxiolytics and hypnotics, at higher doses. Autistic people tended to receive more psychotropics in total and at higher cumulative doses, a pattern that persisted post discharge. A third of the sample were admitted on regular anti-psychotic medications despite having no corresponding psychotic diagnosis, a proportion that remained relatively stable through discharge and into the community.Originality/valueThis study highlights subsets of the intellectual disability population at particular risk of receiving high doses of psychotropics and a feasible template for providers intending to undertake STOMP-focused evaluations.

The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience.

Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders' perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.

Pattern of prescription of psychotropics (antipsychotics, antidepressants and benzodiazepines) in Western Australian residential aged care facilities.

Behavioural and psychological symptoms of dementia are exhibited by up to 90% of residents in aged care facilities and are associated with a risk of inappropriate use of psychotropic drugs. This study examined the prevalence pattern of psychotropic drug use in 409 residents from 11 residential aged care facilities in Western Australia. Sixty-four (n = 64; 15.6%) residents were not prescribed any psychotropic drug, 345 (84.4%) were prescribed at least one psychotropic drug and between 4 and 10% were prescribed high doses, depending on the class of psychotropic. Despite increasing awareness of inappropriate psychotropic drug use in this population, targeted and effective interventions are required to improve psychotropic prescribing practices.

Psychotropic prescribing practices in adults with intellectual disability and autism spectrum disorder in Richmond Neurodevelpmental Services

AimsOur aim was to evaluate psychotropic prescribing practices in adults with intellectual disability (ID) and autism spectrum disorder (ASD) across the Richmond Neurodevelopmental Service (NDS).Stopping over-medication of people with a learning disability, autism or both with psychotropics (STOMP) aims to reduce the potential harm of inappropriate use of psychotropic medications. We aimed to evaluate our prescribing practices in keeping with STOMP and the NICE guidelines.MethodWe collected information from our clinical records on patients that met the inclusion criteria (≥18 years + diagnosis of ID and autism) from October-November 2019. We gathered the following: age, sex, severity of ID, psychiatric diagnoses, psychotropic medication, presence of challenging behaviours, involvement of positive behaviour support (PBS) and documentation of a PBS plan.Result32 patients met our criteria (3:1 Male-Female ratio with an age range of 20-74 (Median 33 years old)). All 32 patients showed evidence of challenging behaviours. In the cohort, mild ID represented 18.8% (n = 6), moderate ID 40.6% (n = 13) and severe ID 40.6% (n = 13).17 patients (53%) had a PBS plan in place. For those without a PBS plan (47%, n = 15), a referral to behavioural analysis had been considered/requested in 67% (n = 10).31 patients were on psychotropic medication and 84% (n = 26) had an indication documented in the notes although every patient had had a medication review in the last 6 months. 67.7% (n = 21) of the prescriptions were for challenging behaviours.The average number of medications prescribed was 2 (median 2, mean 2.41) but this was reduced to 1 (median 1, mean 1.76) when additional psychiatric diagnoses and epilepsy were excluded.ConclusionPrescriptions are regularly reviewed in keeping with STOMP guidance but there is more scope for utilising behaviour analysis input as well as the need to improve documentation of the rationale for psychotropic medications.

Choosing wisely? Quantifying the extent of three low value psychotropic prescribing practices in Australia

BackgroundThe global Choosing Wisely campaign has identified the following psychotropic prescribing as low-value (harmful or wasteful): (1) benzodiazepine use in the elderly, (2) antipsychotic use in dementia and (3) prescribing two or more antipsychotics concurrently. We aimed to quantify the extent of these prescribing practices in the Australian population.MethodsWe applied indicators to dispensing claims of a 10% random sample of Australian Pharmaceutical Benefits Scheme beneficiaries to quantify annual rates of each low-value practice from 2013 to 2016. We also assessed patient factors and direct medicine costs (extrapolated to the entire Australian population) associated with each practice in 2016.ResultsWe observed little change in the rates of the three practices between 2013 and 2016. In 2016, 15.3% of people aged ≥65 years were prescribed a benzodiazepine, 0.5% were prescribed antipsychotics in the context of dementia and 0.2% of people aged ≥18 years received two or more antipsychotics concurrently. The likelihood of elderly people receiving benzodiazepines or antipsychotics in the context of dementia increased with age and the likelihood of receiving all three practices increased with comorbidity burden. In 2016, direct medicine costs to the government of all three practices combined, extrapolated to national figures, were > $21 million AUD.ConclusionsOur indicators suggest that the frequency of these three practices has not changed appreciably in recent years and that they incur significant costs. Worryingly, people with the greatest risk of harm from these prescribing practices are often the most likely to receive them.

Quality indicators of psychotropic prescribing to people with dementia in aged psychiatry inpatient units

ABSTRACTObjectives: To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia.Method: The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and ‘as needed’ psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans.Results: The most problematic areas concerned the gathering of information about patients’ psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services.Conclusion: The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.

Best Practices: MEDNET: a multistate policy maker-researcher collaboration to improve prescribing practices.

States face new federal requirements to monitor psychotropic prescribing practices for children and adults enrolled in Medicaid. Effective use of quality measurement and quality improvement strategies hold the promise of improved outcomes for public mental health systems. The Medicaid/Mental Health Network for Evidence-Based Treatment (MEDNET), funded by the Agency for Healthcare Research and Quality, is a multistate Medicaid quality collaborative with the Rutgers University Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes. This column describes the development, infrastructure, challenges, and early evidence of success of this public-academic partnership, the first multistate Medicaid quality improvement collaborative to focus on psychotropic medications.

Paediatric psychotropic prescribing practices in Ireland

This study describes the attitudes, knowledge and prescribing of psychotropic medication in children. A study-specific questionnaire was mailed to all child psychiatrists, paediatricians and a group of registered general practitioners (GPs) from a selected Child and Adolescent Mental Health Services catchment area. In the 116 respondents who replied (39% response rate), psychotropic medication was generally valued and used by all groups (70.1%). Respondents believed that the majority (61.9%) of their non-medical colleagues would also value/support the use of medication and this endorsement influenced the respondents' prescribing rates. Initiating medication was viewed as the province of child psychiatry (78.6%). Medication is felt to be justified in a wide variety of mental health disorders, their use being reserved for severe presentations, with psychostimulants and selective serotonin reuptake inhibitors being most used. A significant number of GPs (60.9%) and paediatricians (63.4%) were felt to be lacking in competence in psychotropic prescribing, with a general request for more seminars in this area (61.5%) with almost half (45%) of them believing that they would prescribe more often. The use of psychotropic medication in children remains a valued and common practice in Ireland. Attitudinal and practice differences across professional groups exist, and although the experience is one of relative safety there was a strong desire for further education leading to a perceived increase in utilisation. The impact of perceived public opinion regarding psychotropic prescribing along with a lack of competence may represent a major barrier to effective prescribing, thus highlighting the importance of ongoing professional development and increased public health initiatives to increase knowledge and understanding in this increasingly important area.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

This study sought to identify and characterize rates of clinically questionable prescribing in New York State. As part of a quality improvement initiative, 34 national psychopharmacology experts identified a set of questionable prescribing practices recognizable from pharmacy claims data. Indicators of such practices were applied to Medicaid claims data for 217,216 beneficiaries in New York State who had an active psychotropic prescription on April 1, 2008. A total of 156,103 (72%) of these beneficiaries had one or more continuing (>90 days) prescriptions for a psychotropic. About 10% of adults were prescribed four or more psychotropics concurrently, and 13% of children and 2% of older adults were prescribed three or more concurrently. Prescribing an antipsychotic with a moderate-to-high risk of causing metabolic abnormalities approached 50% (46%) among individuals who had existing cardiometabolic conditions. Among beneficiaries prescribed second-generation antipsychotics with a moderate-to-high risk of causing metabolic abnormalities, over half (60%) had not received a metabolic screening test in the past year. Among women of reproductive age prescribed mood stabilizers, over one-quarter (30%) were prescribed a valproic acid-based formulation despite its potential for teratogenicity. Only 2% of youths under age 18 were prescribed benzodiazepines; however, about half (48%) had trials over 90 days' duration. Examination of pharmacy claims from Medicaid beneficiaries in New York State indicated that prescribing practices deemed clinically questionable by pharmacology experts are common. Aggregated pharmacy claims data can identify such practices, and reviews of these data can be a core component of efforts to improve prescribing practices.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

Prescribing practices of psychiatrists and primary care physicians caring for children with mental illness

Although several studies have found that the most effective treatment for both youths and adults diagnosed with mood disorders is the combination of psychotherapy and medications, psychiatrists have been increasingly providing psychotropic medications without psychotherapy to these populations. At the same time, primary care physicians (PCPs) have become increasingly involved in prescribing psychotropic medications. This study compared the prescribing patterns of PCPs and psychiatrists caring for children with mental illness. Data were extracted from the MarketScan database, which compiles claims from private health insurance plans nationwide. Of 40,639 children who received mental health services during calendar year 2000 (6.33% of all covered children), we identified 5485 who initiated a new episode of treatment. Multiple regression was use to adjust for differences in patient characteristics. While PCPs were more likely to see young children and psychiatrists saw children with more numerous mental illnesses, there were no significant differences between PCPs and psychiatrists in either the proportion of patients who received psychotropic medication, the frequency of clinical contacts, or the dosages or types of medications prescribed. Patients seen in more actively managed Point of Service plans were more likely to receive medication than those seen in preferred provider or indemnity plans. This study found no significant differences between psychiatrists and PCPs in psychotropic prescribing practices. In view of the limited availability of child psychiatrists and the decreased availability of psychotherapy in combination with medications, collaborative care models in which non-physician mental health specialists and PCPs work together may increase the availability of effective mental health services for youths.

Psychotropic prescribing practices of paediatricians in the UK.

This study examines the prescribing practices and attitudes to psychotropic medication by paediatricians in the UK. Questionnaires were sent to 100 randomly chosen paediatricians in the UK to assess their prescribing practices of psychotropic medication in children. Paediatricians see and treat many children with a wide variety of psychotropic medications on a regular basis. However, few of them feel competent, and most requested regular psychopharmacology seminars. In the US, primary care physicians and paediatricians are recognized as primarily responsible for the continuing increase in psychotropic prescriptions in children. This study shows that, in the UK, paediatricians also contribute to such prescribing and need to be taken into account when estimating the prevalence and appropriateness of such medication use in children.

A survey of family physicians and psychiatrists: Psychotropic prescribing practices and educational needs

The purpose of this study was to compare the psychotropic prescribing practices of family physicians and psychiatric physicians, and to assess their satisfaction with education about psychotropic prescribing. A survey was mailed to 461 active members of the Minnesota Psychiatric Society and to a randomized sample of 461 active members of the Minnesota Academy of Family Physicians. Major depression, panic disorder, and dementia with behavioral disturbance were selected for study. For each disorder, we asked for the estimated number of patients seen and treated as well as a list in order of preference of the three medications they most commonly use. Those surveyed were also asked about their level of satisfaction with the training they received in medical school, residency, and continuing medical education (CME) courses on the topic of psychotropic prescribing. The two physician groups reported similar prescribing practices for the single-drug treatment of depression. Family physicians more frequently prescribed minor tranquilizers and older generation psychotropics than did psychiatrists when treating panic disorder and dementia with behavioral disturbance. Patients with depression were the least likely to be referred to other health professionals. Neither physician group was satisfied with medical school education in this area; family physicians were less satisfied with residency training and in related CME courses than were psychiatric physicians. Additional study is needed to better understand interspecialty practice variation for commonly encountered psychiatric disorders. Medical education programs at all levels could better meet the reported needs of their graduates by providing more attention to prescribing psychotropic agents.

A ten-year review of the effect of OBRA-87 on psychotropic prescribing practices in an academic nursing home.

The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) included provisions for regulating the use of psychotropic medication, particularly antipsychotics, in long-term-care facilities. The study examined the effect of OBRA-87 on patterns of prescribing of psychotropic medication in a 514-bed nursing home affiliated with a large medical school. Computerized pharmacy records for the ten-year period from March 1984 through July 1994 were retrospectively reviewed to identify orders written for psychotropic medications and to determine the percentage of nursing home residents who received prescriptions for those agents and the average daily dose of the most frequently prescribed agents. During the period before implementation of the regulations, the percentages of residents who received antidepressants, anxiolytic and sedative-hypnotic medications, and antipsychotic medications were stable. After implementation, prescription of antidepressants increased significantly, coinciding with a reduction in prescription of anxiolytics and sedative-hypnotics and a substantial decrease in prescription of antipsychotics. The total number of residents who received any type of psychotropic medication decreased, and over time a trend toward prescription of agents recommended for geriatric use, such as short-acting benzodiazepines and tertiary tricyclic antidepressants, emerged. The changes that resulted from the OBRA-87 regulations reffect both the restrictions placed on classes of medication and the prevalence of psychiatric disorders in the nursing home. In this facility, OBRA-87 appears to have served as an impetus for clinical review and change in practice style.

Consultation-liaison elective for primary care residents

Former internal medicine ( N = 24, 88.9%) and psychiatry residents ( N = 13, 100%) who shared time on a consultation-liaison service responded to a survey assessing their educational expectations and the ability of the rotation to meet these. Internists rated the time spent with patients (54.2%) as most valuable and requested more psychiatric training (70.8%) to enhance supportive therapy. All psychiatrists reported they most benefited from exposure to the medically ill patient (100%) and learning about organic brain disorders (92%). A comparison of psychotropic prescribing practices indicated that internists were comfortable prescribing anxiolytics and antidepressants more frequently than the psychiatrists advised they should be. The internists remained positive about the value of psychiatric consultation and recommendations. Both psychiatrists and internists felt they benefited from the experience and urged continuation of the joint rotation. Recommendations to increase rounding time and resident-to-resident presentations might further enhance the mutuality both groups highly valued.

The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes.

The authors prospectively studied psychotropic prescribing practices and quality assurance data in 17 nursing homes in the Baltimore area to assess the impact of federal antipsychotic drug regulations. There was a 36% reduction in prescriptions for neuroleptics over 6 months, no increase in prescriptions for sedative/hypnotics, and a small increase in prescriptions for antidepressants. The authors conclude that psychotropic drug prescribing practices and patient outcomes remain important areas of study in nursing homes.

Psychotropic prescribing practices Of 3 general practitioners in Italy

Psychotropic prescribing practices Of 3 general practitioners in Italy