Antipsychotic polypharmacy: a survey of discharge prescriptions from a tertiary care psychiatric institution.
ABSTRACT To perform a retrospective survey of discharge medications at a tertiary care psychiatric facility and to assess the incidence of antipsychotic polypharmacy.
This is a retrospective survey that used the Department of Pharmacy's computer database to obtain relevant discharge information on all nongeriatric patients with schizophrenia discharged from Riverview Hospital between November 1, 1996 and October 31, 1998. From a total of 492 eligible patients, 229 met the inclusion criteria and formed the database for the survey.
The main finding of the survey was that 27.5% of our discharged patients diagnosed with schizophrenia left our facility on an antipsychotic polypharmacy regimen. Compared with patients discharged on a single antipsychotic, the pooled data revealed a significantly greater use of anticholinergic agents in those patients prescribed an antipsychotic polypharmacy regimen. Further, of the atypical agents, only risperidone showed a statistically significant reduction in dosage when coprescribed with a second antipsychotic.
Although antipsychotic polypharmacy persists today, as it has over the past 30 years, evidence-based data to support this controversial treatment strategy is lacking. As a result clinicians are relying on their clinical experience, and perhaps intuition, to design antipsychotic polypharmacy treatment protocols. Efforts should be made to replace subjective clinical impression with a more rational approach to antipsychotic polypharmacy--one that is based on pharmacodynamic and pharmacokinetic understanding of drug action.
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ABSTRACT: Dear Editor – While most of us would agree that bacterio-logical, chemical, accident prevention and suicide prevention strategies need to be worked into our mental health as well as general hospital facilities, it has become quite clear that some of these measures are not appropriate in a domestic setting. An important part of rehabilitating clients of the psychiatric services is their training in activities of daily living. However it appears that the institutional standards are being generically applied to all institutions, no matter how small, sometimes to the severe disadvantage of psychiatric rehabil-itation to the extent that it endangers the function of our day centres. We have recently had visits from environmental health officers who suggest that our clients should not have access to cooking knives, that they are only allowed to drink tea in a designated dining area, and that they have to follow the same complicated mop and bucket protocol as any large institution. This means that clients in residences may be left waiting for dinner as some tables are in kitchen areas in smaller residences, their clients will never be judged to be able to assist or take over cleaning and maintenance of their own living areas or kitchens, and will be prevented from either being able to prepare food properly or to handle normal living situations. Ultimately the effect of current environmental health legislation is that, rather than learning to live in a home, clients are learning to live in an institution, and their ability to substantially participate in the running of a home is being mili-tated against. Where local environmental health officers insist on follow-ing the letter of the law it appears there is no way for clients to improve their functioning in day centres or psychiatric resi-dences unless some kind of derogation is made, especially for smaller staffed residences and day centres with ADL train-ing. Perhaps we need to be reminded that 50 years ago clients were regularly involved in all kinds of 'dangerous' work, such as farm work, laundries, kitchens, shoe repair and tailoring facilities.. 'He found the premier asylum a gloomy prison … and he left it presenting the twofold aspect of a hospital and a hive of industry where the bodily strong found occupation and relief … he was no mere administrator but essentially a physician' . He was widely versed in the continental literature and served as joint editor of the Journal of Mental Science. 4 He used adversity in the shape of an epidemic of dysentery and outbreaks of beri-beri to rail against overcrowding, and succeeded in persuading the authorities to build an auxiliary asylum at Portrane – even while he argued that overcrowd-ing could be alleviated by allowing harmless lunatics to be cared for outside in the community. In his presidential address to the Royal Medical Psychological Association in the Royal College of Physicians in January 1894 he bewailed the institutionalisation of staff as a result of unremitting care and toil with trivialities. Norman suffered from angina pectoris for the last twelve years of his life. He developed influenza with bronchitis in December 1907, and only resumed duties on the Monday before his sudden death after walking a couple of hundred yards from his home on Sunday February 23, 1908. Acknowledgements: Librarians Mary O'Doherty RCSI and Robert Mills RCPI very kindly tracked down the obituary notices for me.
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ABSTRACT: The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9–16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3–10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5–24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology 04/2014; DOI:10.1016/j.euroneuro.2014.01.014 · 5.40 Impact Factor
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ABSTRACT: This is the protocol for a review and there is no abstract. The objectives are as follows: The primary objectives of this review are to examine whether: Treatment with antipsychotic combinations is effective for schizophrenia; andTreatment with antipsychotic combinations is safe for the same illness.Cochrane database of systematic reviews (Online) 01/2011; DOI:10.1002/14651858.CD009005 · 5.70 Impact Factor